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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.42 Diagnostic and Therapeutic Breast Procedures : 9.2.42.2 Therapeutic Procedures

9.2.42.2
9.2.42.2.1
Mastectomy and partial mastectomy (e.g., lumpectomy, tylectomy, quadrantectomy, and segmentectomy) are benefits when it is medically necessary to remove a breast or portion of a breast for conditions including, but not limited to:
The following procedure codes for mastectomy are benefits of Texas Medicaid:
 
Procedure codes 19301, 19302, 19303, 19304, 19305, 19306, and 19307 may be reimbursed without prior authorization for services rendered to male or female clients who are 18 years of age and older.
Prior authorization is required for services rendered to clients who are 17 years of age and younger.
Procedure codes 19303, 19304, 19305, 19306, and 19307 are limited to 1 service per breast per lifetime.
9.2.42.2.2
Prophylactic mastectomy is a benefit after a thorough assessment of a client’s unique risk factors, health, and the level of concern. Prophylactic mastectomy is limited to clients who are at moderate- to high-risk for the development of breast cancer.
Moderate- to high-risk clients are those who meet one or more of the following criteria for development of breast cancer:
Refer to:
Subsection 2.2.6, “Breast Cancer Gene 1 and 2 (BRCA) Testing” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).
Documentation that supports medical necessity for prophylactic mastectomy must include the information listed above.
Documentation that as a candidate for prophylactic mastectomy, the client has undergone counseling regarding cancer risks. Counseling must include assessment of all of the following:
9.2.42.2.3
Mastectomy for pubertal gynecomastia is a benefit with prior authorization for males who are 20 years of age and younger. Procedure code 19300 may be reimbursed for mastectomy for pubertal gynecomastia.
The following documentation must be submitted with the prior authorization request for procedure code 19300:
Evidence that the client has been off gynecomastia inducing drugs or other substances for a minimum of one year when this is identified as the cause of the gynecomastia.
Evidence of resolution as supported by appropriate test results and treatment for hormonal causes, including hyperthyroidism, estrogen excess, prolactinomas, and hypogonadism, for a minimum of one year when identified as the cause of the gynecomastia.
Documentation that supports medical necessity for mastectomy for pubertal gynecomastia must be maintained in the client’s medical record, and must include the following:

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